health: An Interdisciplinary Journal

for the Social Study of Health,

Illness and Medicine
Copyright © 2007 SAGE Publications
(London, Thousand Oaks and New Delhi)
DOI: 10.1177/1363459307083696
Disciplining death: Vol 12(1): 25 –42

hypertension management
and the production of
mortal subjectivities

Albert Banerjee
York University, Canada

a b s t r a c t Medicine powerfully mediates the relationship between life

and death. This article argues that in the name of health, modern medicine
constitutes a pathological mortal subjectivity, encouraging individuals to
experience death as disease, to understand mortality as morbidity, and to
approach living instrumentally as a means to longevity. This article uses the
example of hypertension management to illustrate how this vision of death is
transformed into a form of life. Through the analysis of a number of disciplinary
technologies – from technical definitions of health to blood pressure
monitoring – it illustrates how individuals are incited to relate to death in
an antagonistic, impersonal, and technical fashion. While contemporary forms
of capital accumulation in the health field require an intensification of such
relations, this article suggests that there much to be gained from exploring
visions of health that are not at odds with death.

keywords death; discipline; health; hypertension; subjectivity

a d d r e s s Albert Banerjee, Department of Sociology, York University,

2060 Vari Hall, 4700 Keele St., Toronto, ON, M3J 1P3. Canada.
[e-mail:balbertb@yorku.ca]

a c k n o w l e d g e m e n t s I am grateful to Greig de Deuter and Sachne J.

Kilner for their many insightful comments and contributions.

[T]he dying man is given food and water intravenously, thus sparing him the
discomfort of thirst. A tube runs from his mouth to a pump that drains his mucus
and prevents him from choking. Doctors and nurses administer sedatives, whose
effects they can control and whose doses they can vary. All this is well known
today and explains the pitiful and henceforth classic image of the dying man
with tubes all over his body.
(Phillipe Ariès, 1981: 584)

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Introduction
Our relationship to death has increasingly been shaped over the last two
centuries through medical discourses and practices. Yet contemporary
forms of Western medicine afford a very narrow set of orientations towards
human mortality. The ‘person with tubes all over their body’ that Ariès
(1981) describes as the classic image of death is one product of this relation.
We would be mistaken, however, to consider this figure an end-of-life
creation. Quite the contrary. Such deaths are the culmination of a series of
lifelong preparations – one is trained to die in this way. The aim of this article
is to use hypertension management to suggest how this process occurs.
This article extends a line of scholarship analysing medicine’s influence
on prevailing notions of death by considering its effect on how we live as
mortal beings. Within this tradition, scholars have argued that biomedicine
has radically altered the ‘nature’ of death (cf. Bauman, 1992; Lock, 2002;
Prior, 1989). Their analyses point to a number of key transformations, the
most significant being the shift from a vitalist to a mechanist ontology, in
which death came to be seen as the effect of physical lesions rather than
their cause (Foucault, 1973). The impact of this mechanist gaze was the
containment of death – materially within the body and temporally at the
end of life. No longer was death represented by a cloaked figure with which
one danced throughout life, but by the disease that ended life. This logic
removed death from the realm of personal agency (Prior, 1984). Dying, as
a biomechanical process, was transformed from life’s last great act – an act
that one had the obligation to prepare for – to an event that seemingly
happened to people (Ariès, 1981). Responsibility for death was transferred
to professionals, who had the tools to see death, measure its approach, and
suggest appropriate courses of action (Illich, 1976)
Armstrong’s (1993, 1995) work on surveillance medicine suggests that
this framework has altered of late: death is now materialized within the
lifespan, albeit even more obliquely, through the concept of risk. Coupled
with discourses of health promotion, surveillance medicine presents
the possibility that individuals may now do something about their dying
(Bauman, 1993a). Nonetheless, what they can or medically ought to do is
limited to strategies of risk management.
Both biomedicine and surveillance medicine are expressions, as
Callahan (1998) has observed, of the modern project of dominating nature.
The belief that humans stand above, and are destined to control, nature is
written into medical encounters with death. Whether death is conceptual-
ized through the metaphors of pathology or risk, death is positioned as
an enemy to be systematically sought out and destroyed. The result is the
dedication of a staggering amount of resources to fighting causes of death.
The hospice/palliative care movement has gone some way towards
enabling a more compassionate response to death. In doing so, they have

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 Banerjee: Disciplining Death
worked to shift the representation of death from pathology to an oppor-
tunity for growth – an opportunity that requires the dying person’s active
participation (Byock, 1997). While potentially liberating, sociologists and
anthropologists alike have cautioned that hospice enmeshes the dying
within a different set of potentially oppressive power relations (Armstrong,
1987; Hockey, 1990). In this case, speaking one’s truth and overcoming
challenges becomes the new orthodoxy. Forms of dying that would appear
to short-circuit opportunities for growth – euthanasia and assisted suicide
especially – become problematic in this regard (Banerjee, 2005).
Perhaps one of the greatest limitations of hospice as a corrective to
medicine’s hostile agenda is simply that it comes too late. Central to the
argument put forward in this article is that death is not an end-of-life issue.
Rather life and death stand in intimate relation. On the one hand, how indi-
viduals understand their own impermanence has important consequences
for the ways in which they live, for the ethical judgments they make around
what is good (or healthy), and for the modes by which they relate to them-
selves and others. On the other hand, dying is learned. Throughout life,
individuals learn from a diversity of sources how to think about death, they
learn to judge certain responses to mortality as appropriate and responsible,
and they are taught how to prepare for dying.
This article approaches medicine as a powerful mediator of the relation-
ship between life and death.1 Medicine offers ways of understanding death
and strategies for responding to signs of mortality that have real effects in
the midst of life. What is at stake in this analysis is the creation of subject-
ivities and ways of living. The term ‘mortal subjectivity’ is used here to cap-
ture who we are and how we live as mortal beings. My contention is that
bio-medicine constitutes a pathological mortal subjectivity: one that stands
against death. Individuals, within this logic, are incited to become allies in
the war against death, they are encouraged to experience death as disease,
to see mortality as morbidity, and to organize their lives around battling
specific instances of each.
As one response to mortality, this pathological subjectivity has its
merits – not the least of which is the potential and often very real extension
of lifetime. However, this article is motivated by a concern that the pressure
to take up this subjectivity is becoming increasingly intense as a result of
economic imperatives. As Weber (2001[1904]) observed just over a century
ago, capitalism benefits from the formation of particular subjectivities.
The Protestant ethic fostered the development of traits – e.g. thrift, temper-
ance, hard work – that encouraged the accumulation of capital. Today, the
growth of industry, especially within the health field, requires a different
subject – one who is less concerned with predestination and more concerned
with high-tech forms of prevention.
With this in mind, the current article uses the example of hypertension man-
agement to elucidate how medicine constitutes a pathological relationship

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health: 12(1)

to mortality. Drawing on Foucault’s (1977) concept of discipline2, this article

offers an analysis of a number of disciplinary technologies from blood
pressure monitoring to drug therapy that, while integral to hypertension
management, also train individuals to understand death as series of real
or potential diseases and encourage them to respond to symptoms through
medical intervention. The analysis presented is preliminary at this point as
it focuses only on the technologies and the tacit assumptions behind them.
It probes neither the myriad of ways individuals actually take up, resist
or ignore these practices nor the way physicians interpret or implement
treatment guidelines.

Historical background: From high blood pressure to

hypertension
Some 600 million people worldwide have high blood pressure and nearly 3 million
die every year as a direct result. (WHO, 1999: 293)

Hypertension is one of many existential discourses medicine provides to

govern the mortal body. Hypertension matters because of its relationship
to death. Through the concept of risk, hypertension has been linked to heart
disease and stroke – causes which account for 30% of the world’s fatalities
(Thomas and Rocella, 1999). Hypertension has thereby been constituted
as one of the most pressing global health problems (WHO, 2002). Affecting
over half a billion people, hypertension has been labelled a ‘world-wide
epidemic’ (Mulrow, 1999). These numbers, however shocking, hide the
gradual medicalization of blood pressure.
At the turn of the 19th century, high blood pressure was considered a
normal part of aging (Postel-Vinay, 1996). Statisticians working for the insur-
ance industry were the first to correlate blood pressure levels with mortality
and to argue for the pathologization of high blood pressure. Epidemiological
knowledge, however, was not readily accepted by the medical profession
as a basis for clinical action (a situation which finds its reversal in the
development of evidence-based medicine; Mykhalovskiy and Weir, 2004).
Even when the relationship was acknowledged, little was done. For there
was little to do. It was only with the development of ganglion blockers in
1951 that the modern era of hypertension treatment began (Le Fanu, 1999).
Even so, the side-effects of drug therapy were serious and treatment was
limited to patients suffering from debilitating symptoms. The severity of
side-effects further necessitated specialized sites (‘hypertension clinics’)
for medical supervision. New drug discoveries throughout the 1960s and
beyond made treatment easier to administer and reduced side-effects. With
the ability to treat to lower levels of blood pressure came changes in the
definition of hypertension and the medicalization of moderate and eventu-
ally mild blood pressure (Kawachi and Conrad, 1996)

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 Banerjee: Disciplining Death

The medicalization of blood pressure has created mass ‘sickness’. One

study estimates that 33% of Americans are hypertensive (Fields et al., 2004).
Similar rates have been found for Canadians (34%; Petrella and Campbell,
2005) and for the British (37%; Lloyd et al., 2003). Perhaps more worrisome
is that the risk of developing hypertension increases with age. American
adults 55 years and older have a 90% chance of developing high blood
pressure (Chobanian et al., 2003). With ever-lowering norms, hypertension
has become a condition everyone suffers. And yet, the vast majority of
cases – 95% – produce no noticeable symptoms and have no known cause
(Rudd, 2000). Indeed, nearly half of all those with hypertension are not
aware they have it (Joffres et al., 1997).
There are many reasons to be concerned with the continued extension of
hypertension to the general population. Most obvious is the cost of chronic
drug use, for hypertension is rarely cured, but managed through a lifetime
of drug taking (Gregoire, 1998). As well, the emphasis on pharmaceuticals
in both research and therapy result in the neglect of both the social causes
of hypertension and the potential effectiveness of nondrug therapies
(Raphael, 2002). There are also ethical concerns around a programme of
mass screening, diagnosis, and treatment. Is the potential to prevent one
incident of heart disease worth the economic, social, and emotional cost?
These are valid considerations and, of themselves, warrant scepticism of the
increasing intensity surrounding hypertension management. While they
find their way into this article, my primary interest has to do with the
mortal subjectivities produced through hypertension management and
the possibilities and limitations they offer for living well.

A metaphysical Trojan horse

The advent of biomedicine 200 years ago transformed the natural into the
pathological death. (Armstrong, 1993: 79)

This article has its origins in a doctor’s waiting room and the chance finding
of a health promotion pamphlet, entitled High Blood Pressure: The Silent
Killer, published by the British Columbia Medical Association (BCMA,
1991). Being one in a series, this pamphlet follows a standard format: ex-
plaining in layperson’s terms the physiology of blood pressure, describing
the pathology of hypertension, explaining its significance as a potential
cause of death, and optimistically outlining forms of intervention including
drug therapy and lifestyle modification. Educational pamphlets such as this
one are an integral part of the promotional strategy of the medical com-
munity, engaging and informing the public in the name of health. As the
copy explains, this pamphlet was produced ‘by your physician and the
British Columbia Medical Association to promote better health care’. It
concludes with the following slogan: ‘B.C. Doctors. A commitment to good
health’.

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health: 12(1)
Reading the pamphlet within the context of a doctor’s office helps frame
its interpretation as factual and well intentioned. The above statements
add to this perception. Certainly, at first glance, educating the public in
the name of ‘good health’ is what the pamphlet appears to do, providing
little more than factual information and practical advice on how to deal
with the specific problem of hypertension. However, stepping out of the
medical context, one may see, as Bauman (1993b) suggests, that these
sorts of pamphlets convey a wider and much more influential message.
They position the reader within an entire worldview; in this case, within
the medical vision where death is represented through the metaphors of
risk and pathology. While the pamphlet only references a few of these –
high blood pressure, obesity, stroke, and heart disease – it simultaneously
privileges an antagonistic, reductionist and materialist interpretation of
death and it encourages the public to experience aging and dying as a series
of physiological pathologies. Indeed, far from being merely informative,
this pamphlet operates as a metaphysical Trojan horse, concealing the
medical worldview between the lines of medical ‘facts’.
Pamphlets such as the above might be understood as disciplinary tech-
nologies, which, although seemingly innocuous, are wholly integral to the
maintenance and extension of medical power. I am using the word ‘tech-
nology’ here in the Foucauldian sense to refer to a set of ‘modest’ techniques
which facilitate the rationalization, control, and ultimately the governance
of human subjects (Foucault, 1977: 139). Thus, while the authors of the
pamphlet claim to be educating the public, the pamphlet operates less as
a teaching device than a training mechanism, since the central existential
assumptions around who we are and how we ought to relate to death are
tacit. What matters from the perspective of discipline is not that we know
these assumptions and can speak them, but that we perceive ourselves in
particular ways and respond in appropriate manners. Nothing more. The
often silent nature of disciplinary technologies is why it is particularly
important to elucidate what they are and how they function.
One technique central to health education literature is the production
of fear. This ‘pedagogy of danger,’ as Crawford (2004) has termed it,
‘authorizes extreme measures’ in the name of reducing suffering (p.509).
It is clearly at work in public education around hypertension. On the one
hand, dangers are exaggerated (e.g. relative rather than absolute risks are
provided) and harmful consequences are also inflated (e.g. people do not
die ‘directly’ from essential hypertension). On the other hand, hope is
offered. But it is a restricted hope; for to qualify, one must pass through
medicine. In this manner, one’s relationship to mortality – we might say
one’s dance with death – is transmuted into a professional ritual comprised
of a new sort of dance team: that of the physician and the at-risk individual,
spiralling around a disease, arm-in-arm, so that it is no longer a simple ques-
tion of who’s leading whom. The dance is set to happy music. What is never

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 Banerjee: Disciplining Death
said, and what makes the medical promise so seductive, is that the person
will simply die of something else:
If you have had high blood pressure but you control it carefully, you will avoid
nearly all risk of heart failure and considerably reduce the likelihood of stroke.
Hypertension is a condition that can be handled very effectively by a team – you
and your doctor working together. (BCMA, 1991)

In what follows, this pamphlet will serve as a springboard to explore the

various technologies through which hypertension discourse produces a
pathological mortal subjectivity. A good place to begin is the way in which
this pamphlet constitutes the meaning of health.

Technical definitions of health

If left untreated, mild to moderate high blood pressure cuts life expectancy by
three to six years, on average, and severe hypertension can cut life expectancy
by eight years or more. (BCMA, 1991)

One of the principal strategies employed to manage hypertension involves

training the public to understand and experience health as a technical
phenomenon. Central to this approach is the production of a Cartesian
subject. This requires splitting the Self into mind and body. The mind – the
person’s thoughts, feelings, hopes, dreams, ambitions etcetera – have no
relevance to technical definitions of health and are ignored in the defin-
ition of hypertension. The body, which is central in this materialist paradigm,
is constituted as a mechanical entity, an understanding which may be
conveyed through comparison to familiar machines, such as automobiles
and household plumbing. The problem of hypertension is thus explained:
As your heart pumps blood through your arteries, the force of the blood flow
exerts pressure on the arterial walls, just as air pumped into a tire exerts pressure
on its lining and surface. Just as too much air pressure eventually shortens the
life of a tire, too much blood pressure will eventually damage the arteries… .
(BCMA, 1991, italics my own)

Reading this, one comes to understand illness not as subjective phenomena,

such as pain, discomfort or the frustration of desired goals but as a technical
problem: one is healthy so long as certain functional criteria are achieved
and sick when they are no longer met. In the case of hypertension, the
disease occurs when the pressure within the blood vessels reaches a level
determined by expertise to be above normal parameters. Ill-health is thus
contained in the interface between the mechanical body and scientific
norms. It exists as a set of numbers:
Blood pressure is always expressed in two numbers; for example ‘120 over
80’. These numbers represent the systolic (highest) pressure over the diastolic
(lowest) pressure, in terms of how many millimeters the pressure would force

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a column of mercury to rise in a tube. The measurement of 120/80 is within
the normal range… . Sustained high blood pressure (above 140/90) is called
hypertension. (BCMA, 1991, their emphasis)

The quantitative nature of this definition confers an aura of objectivity

and moral neutrality. Nonetheless, as Feldman and colleagues (1999) note,
the setting of hypertension norms is guided by the value of preventing
premature death. The criterion ‘140 over 90’ thus stands for the ethical
belief that the good life is the long life. The privileging of this principle goes
back to the earliest definitions of hypertension. Commenting on their 1939
definition of hypertension, for instance, Robinson and Brucer note that it
was guided by the following logic: ‘Whatever the method of selecting any
physiologic norm, the level cannot be interpreted medically as ‘normal’
unless it is consistent with the longest possible life’ (cited in Kawachi and
Conrad, 1996: 31).
Unfortunately, while the ethic of longevity might seem laudable, because
of the dismissal of subjectivity, these norms become tools for privileging
life independent of its significance for the person. Such techniques thus
contain dangerous potential, which we have witnessed surface in debates
around the right to refuse or withdraw life-sustaining technologies. Al-
though hypertension management may not promote the continuance of
such apparently objectionable existences, the context of this discourse is
an intensely moralizing one that has the effect of framing other forms of
living as offensive and irresponsible. Moral coercion of this sort is clearly
palpable in the following public health message from the US National
Institute of Health:
Today, more and more people are having their blood pressure tested and
controlled. But many others either never bother to check their blood pressure or
stop following their doctor’s orders.
Unfortunately, high blood pressure will not simply go away. Ignoring it is very
dangerous. You must accept that treatment is important. You must also accept
that, while it’s up to the doctor to prescribe the best treatment to lower your
blood pressure, it is your job to follow through with that treatment.
‘Follow through’ includes making lifestyle changes and having your progress
checked, since your treatment needs probably will change over time. For instance,
some people need to cut back on sodium, lose weight, or begin taking a drug …
(NIH and NHLBI, 1994, italics my own)

While there are many fruitful ways of engaging with mortality, within hyper-
tension discourse, healthy living is closed around the ethic of longevity. This
clearly precludes other forms of life and rejects other ethical standards by
which one may determine what is good. However, blood pressure norms
are elegant disciplinary technologies as they provide a way of assessing,
ordering, and governing people in such a way that these ethical debates
rarely arise.

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Surveillance
Getting your blood pressure taken when you are 18, and knowing your numbers,
should be a rite of passage, like getting a driver’s license. (Dr Ross Feldman,
Heart and Stroke Foundation, 2005)

Hypertension is known as the ‘silent killer’ (BCMA, 1991). The choice of

this metaphor is worth thinking about, for being killed is certainly very
different than dying. The term ‘killer’ suggests that there is nothing normal
about dying from heart disease, even though it is the leading cause of death
in industrialized nations (Lopez et al., 2006). The metaphor of ‘killer’
effectively frames one’s relationship to death in terms of antagonisms. This
death is a mistaken, unnatural, if not criminal one. It is not to be tolerated.
In its silence, this killer must be sought out.
Surveillance lies at the heart of hypertension management. While surveil-
lance might involve anything from watching what one eats to searching
for the sodium content on food packaging, its archetype is found in the
clinical examination and the ritual of blood pressure measurement. These
are practices that have become so thoroughly routinized they are nearly
synonymous with visiting the doctor. To get a sense of scope, in Canada,
hypertension is the principal reason for visiting a physician, resulting in
nearly 21 million patient visits annually (this compares to just under nine
million visits for depression, the second most common reason for seeing a
physician; IMS, 2006a).
With the development of portable, easy-to-use digital devices, the ritual of
blood pressure monitoring has extended beyond the clinic, integrating itself
into the everyday routine of a growing number of people. Indeed, the present
US market for blood pressure monitoring equipment is expected to double
to nearly $1 billion by 2012, largely a result of sales of self-monitoring tech-
nology (Frost and Sullivan, 2006). With such potential for profit, it is safe to
predict that corporations will find new and creative ways of further integrat-
ing surveillance into the fabric of everyday living – perhaps literally, as com-
mon garb may come embedded with blood pressure monitoring devices.
Self-surveillance offers a number of advantages over clinical measure-
ments. For one, data gathering is improved as measurements may be taken
repeatedly over the course of a day enabling the compilation of a detailed
log. Second, self surveillance avoids the problem of white coat hypertension,
that is, the exaggerated readings due to the stress of having one’s blood pres-
sure measured by medical staff. Perhaps most importantly is the potential
for self-surveillance to draw individuals deeper into their own medical man-
agement, effecting a heightened commitment to blood pressure control.
The affective dimensions of this practice – e.g. determination and intense
concern – are clearly evident in the following letter from a troubled patient
to Dr Douma (1998), a syndicated medical columnist:
I am a 75-year-old male who has been on medication for hypertension for the
past 25 years. I am taking 40 mg of Lotensin and 25 mg of Maxzine a day. My

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morning pressures are running 170/85 mm Hg; daytime pressures, 145/85 to
165/85; and evening pressures, 130/70 to 150/80. My doctor tells me that at my
age, systolics in the 160’s are normal. Could you advise me if this is true and
why my morning readings are so high, when I’ve been told morning levels
should be low? (B7)

The above quote illustrates how disciplinary power avoids the overt use
of force by working through people rather than on them. Disciplinary
power, as Foucault observed, ‘regards individuals both as objects and
as instruments of its exercise’ (1977: 170). Of course, the above quote also
evidences slippage: one senses confusion and complexity. It echoes the
shifting definitions of the normal and physicians’ differing interpretations
of treatment guidelines. In this quagmire, with life seemingly at stake, the
patient urgently wants to know what is true! This is not an easy question as
what is normal is contested here as in so many other medical fields.
In hypertension discourse, however, there is no contestation around
the correct understanding of death. The risk ritual of monitoring blood
pressure – extending one’s arm, wrapping the cuff, taking some deep breaths
to relax and score well – enacts this technical and impersonal relation-
ship to death. The modern Ars Morendi, as evidenced here, is reconfigured
into the management of a set of numbers: ‘If your morning systolic readings
are consistently 170,’ responds Douma, ‘I would recommend that you talk
with your doctor again about improving this number’ (B7).

Pharmacological technologies
Most people with high blood pressure have relatively mild hypertension, but
mild cases almost always worsen over time without treatment. Even slightly
elevated blood pressure … is thought to be a health hazard if it persists for years.
In most cases, blood pressure rises steadily over a number of years unless it is
treated. (BCMA, 1991)

Antihypertensive drugs are the main technologies employed to normalize

the body. In Canada, 81% of visits to physicians for hypertension resulted
in drug recommendations (IMS, 2006b). The expenditure on antihyperten-
sive medication is staggering. Worldwide, calcium channel blockers and
ACE inhibitors, the two most prescribed classes of antihypertensives,
achieved a total sales of US$17.7 billion dollars in 2002 (IMS, 2003). They
formed the third bestselling group of drugs, close behind cholesterol and
triglyceride reducers, used to manage another risk for heart disease, with a
worldwide sales of US$21.7 billion dollars.
A common myth is that the development of medical technology occurs
in response to a specific problem or need. In the case of hypertension, the
situation has generally been the reverse. The development of pharma-
ceutical technologies has played a key role in the medicalization of blood
pressure.

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 Banerjee: Disciplining Death

As noted, though very high blood pressure was long recognized as a

medical concern, treatment was limited, given the severe side-effects of
most available interventions. With the development of relatively safe drugs
such as clorothiazide and propranolol in the mid 1950s and 60s, hyperten-
sion became a treatable condition (Le Fanu, 1999). However, the ease
by which blood pressure could be reduced posed an interesting dilemma:
what level of blood pressure should physicians treat to? This question led
to an important debate between Robert Platt and George Pickering
(Swales, 1985). Platt argued that hypertension was a discrete disease entity
with a genetic origin. As such, it was possible, if not necessary, to distinguish
between populations with the disease and those without. Pickering, in
contrast, claimed hypertension was not a disease in the conventional sense.
Rather, blood pressure had a continuous distribution within the population
and there was no clear division between the normal and the pathological.
While the higher one’s blood pressure the greater one’s risk of death, any
cut-off point was arbitrary. Within this paradigm, treatment logic was
simple – the lower the better.
Pickering’s paradigm eventually carried the day and marked an import-
ant shift in the nature of illness and a key moment in the rise of surveillance
medicine (Armstrong, 1993). This was also great news for the pharma-
ceutical industry as hypertension could potentially apply to everyone.
Today – with one third of the adult population hypertensive (Thomas and
Rocella, 1999), 90% at risk of developing hypertension (Chobanian et al.,
2003), and recommendations to monitor children as young as three years
of age (AHA, 2005a) – this seems to have become the case.
The tendency towards progressively lower blood pressure norms is
evinced in the most recent round of American and European treatment
guidelines. In the US, these guidelines have created a new category of
illness called ‘prehypertension’ (JNC, 2004). According to these guidelines,
anyone with a systolic blood pressure of 120 to 139 or a diastolic of 80 to 89
is considered prehypertensive and in need of some form of intervention.
This revision has effectively pathologized the once dimilitarized zone
between the normal blood pressure of 120/80 and the pathological blood
pressure of 140/90. These new guidelines increase the number of people
classified as having a medical condition by an estimated 50 million (Moynihan
and Cassels, 2005). The situation is similar in Europe, though the category
there has been labelled ‘high normal’ (ESH and ESC, 2003).
Scholarship on medicalization is paying increasing attention to the role
of the market in driving concepts of health (Clarke et al., 2003; Conrad,
2005). The processes by which financial interests may push medical sci-
ence in particular directions is a complex one, and much critical analysis is
of the ‘guilt by association’ sort. Nonetheless, the associations, especially
in the case of hypertension, are strong. The majority of the studies on which
the above recommendations were founded were funded at least in part
by the drug industry, published in journals sponsored by the drug industry,

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and put together by committees with members having strong financial ties
to the drug industry. Nine of the 11 co-authors of the American guidelines,
for instance, received research funding, speaker’s fees, owned stocks, or
consulted for drug companies (Moynihan and Cassels, 2005).
More to the concern of this article is that capital also benefits from particu-
lar orientations towards death. Certain mortal subjectivities are needed in
order to maintain increasing stock prices, shareholder value, corporate
promotions, market expansion, and to ensure the continued growth of the
pharmaceutical and diagnostic industry. The current organization of global
capitalism requires that death be an enemy. Indeed, it requires a continual
intensification of these hostile relations. Not surprisingly, an increasing
aggression surrounds hypertension management. This intensification is
apparent if we contrast current medical opinions with those of 30 years
ago. In a well-respected 1971 textbook on heart disease, authors Orum and
Heinemann claim that: ‘Hypertension is benign in more than 90 per cent of
patients and malignant in the rest…’ (p.390). Today, there is no such thing
as ‘benign’ hypertension. It has been reclassified as ‘essential’ hypertension
and declared one of ‘the most common and important health problems’
(Health Canada, 2000).
Increasing hostility has significant consequences for treatment. What was
required in 1971 was compassionate reassurance. Orum and Heinemann
advise:
If the raised blood pressure is the sole finding and there is no evidence of
hypertensive heart disease [e.g. it is not a symptom of another disease such
as kidney disease etc.] … no immediate measures other than reassurance are
required. Even so, deterioration may occur and such patients should be seen
regularly, care being taken not to engender a neurosis. A lifetime of continuous
drug therapy is not to be embarked on lightly…. It might be well argued that
treatment is desirable before irreversible changes occur, even in the absence
of symptoms. The problem would be easier if anti-hypertensive drugs were
free of side effects which cause such ‘medication misery’ that many patients
prefer to be happy though hypertensive… (1971: 414, italics in original)
Today the suggestion of being ‘happy though hypertensive’ is virtually
unthinkable and the compassion surrounding high blood pressure has
been replaced by a ferocious campaign. Speaking of the implications of
another industry-funded study, George Carruthers eagerly asserts that: ‘We
need to tell physicians to treat hypertension aggressively. We need to tell
them that it is safe to do so. We need to tell them we can do it’ (Canada AM,
1999). This passionate call to arms was echoed by another of the study’s
authors, Robert Luton, who remarked that these research findings ‘makes
us more aggressive, and it makes the patient more aware and sensitive to
what is going on’.
Of course, what is going on is subject to multiple interpretations. Crawford
(2004), for instance, contends that a distinctive feature of contemporary med-
ical culture is a spiral of control and anxiety. To this we can add aggression.
This spiral is vicious because, as Crawford claims, the desire to achieve
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 Banerjee: Disciplining Death
security through knowledge production and risk management compels a
more finely tuned awareness of contingency. ‘The more that is controlled,
the more apparent becomes that which eludes control’ (Crawford, 2004:
506). Escalation is also spurred by the simple fact that it is more profitable
to seek security through war than to seek alternative responses more
tolerant of death’s eventuality and unpredictability.

Lifestyle modifications
… people who have high job strain and/or low marital cohesion should see their
family doctor for a blood pressure check. (AHA, 2005b)
First-line interventions to normalize blood pressure involve lifestyle
modifications. These strategies are often deployed in the name of prevention,
before the individual has been diagnosed as hypertensive. They involve, as
the BCMA (1991) recommends, the reduction of salt, alcohol and caffeine
consumption. As well, they recommend that individuals quit smoking, take
regular exercise and engage in stress management.
On one level, there appears to be nothing problematic with these sorts
of recommendations. They seem to advise little more than the popular
wisdom of moderation. While the ideal of living a life of moderation is
certainly an ethical guide that may be invoked to judge the degree to which
activities, behaviours, or forms of life are good, the concept of moderation
is ambiguous. In its ambiguity there is space for a variety of lifestyles and
interpretations of healthy living to co-exist.
However, expert recommendations are rarely ambiguous (though they
are frequently contradictory). With regards to drinking, the BCMA (1991)
offers a degree of precision that one has come to expect from expertise. Such
precision suggests a confidence that it is possible to map out the complex
cause and effect processes that will take an individual from drinking to
hypertension to death. The BCMA recommends that individuals adopt the
following posture towards drinking:
Decreasing alcohol consumption. Alcohol contributes to high blood pressure in
about 10 per cent of men and one per cent of women. Alcohol consists of ‘empty
calories’ so it interferes with weight loss efforts [another strategy to reduce
hypertension]. It may also make anti-hypertension medications less effective.
Most experts advise limiting alcohol to two standard drinks per day (a standard
drink is four ounces of wine, 12 ounces of beer, or one ounce of liquor).
In this technico-moral discourse, arguably Western civilization’s favourite
mind-altering drug is constituted as a problem because it thwarts the war
on death by potentially raising blood pressure levels. Drinking is emptied
of any other meanings and relations. It becomes a technical affair – ‘alcohol
consumption’ – and is reduced, literally, to nothing more than ‘empty
calories’. Drinking joins the litany of pleasures that are to be removed from
the lifeworld and technically managed in the name of health, quantified
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health: 12(1)

through the application of a formula that calculates the appropriate daily

dosage for optimal life expectancy: ‘two standard drinks’.
The reduction of living into individual risk factors affords the impression
that death can be scientifically managed and justifies the continued pursuit
of other individual factors – job strain, marital cohesion, red meat, sunshine,
smoking, etc. It legitimates the extension of disciplinary power down to a
‘capillary level’ and ‘the penetration of regulation into even the smallest
details of everyday life’ (Foucault, 1977: 198). But such compartmentalization
keeps difficult questions at bay. In focusing on hypertension, one misses
the fact that there are over 200 risk factors for heart disease alone. When
all these are taken into consideration, the micro-control promised by medi-
cine no longer seems feasible. Indeed, the important question no longer
appears to be how to avoid this or that risk but how should I live, given that
I must die?
Living a good life likely involves the acceptance of some risk and may
well have little to do with longevity, though living long is no doubt desir-
able. One of the cultural side-effects of medicalization, however, is that the
diversity of values that guide living well come to be ordered, if not subsumed,
by the value of health. Crawford (1980) has termed this phenomenon ‘super
health’ whereby ‘more and more experiences are collapsed into health
experience, more and more values into health values’ (Crawford, 1980: 380).
Bauman (1993a) reads this another way, suggesting that ‘fighting causes
of dying turns into the meaning of life’ (Bauman, 1993a: 21). Essentially
they are saying the same thing, since the hegemonic vision of health would
seem to be fixed around longevity. In privileging this vision of health,
something vital is lost: other values, other ways of experiencing, alternative
symbolizations by which people may understand their predicaments, feel
their challenges, formulate their aspirations and guide their actions are
pushed aside or reworked via the grid of health.
As one recent study on hypertension demonstrates, it is even possible
to pass love through this gaze. Finding that marital support contributes
to lower blood pressure levels, the author recommends that: ‘If a harmoni-
ous relationship has deteriorated, blood pressure needs to be checked’
(AHA, 2005b).
At some point, this logic turns in on itself. In the effort to master death,
medicine enables death to infiltrate life and direct ways of living. Paradox-
ically, in a developed society that has attained a certain security from
early death, the intensity of concern around health risks has given rise to
an obsession, albeit in a roundabout way, with our own demise. Death no
longer comes at the end of life; as Bauman (1993a) suggests: ‘it is there from
the start, calling for constant surveillance and forbidding even a momen-
tary relaxation of vigil. Death is watching (and is to be watched) when we
work, eat, love, rest’ (Bauman, 1993a: 21). This is perhaps one of the most
important messages contained in the BCMA (1991) pamphlet: that life
ought to be organized around fighting death, as if forms of living were
themselves medical technologies.
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 Banerjee: Disciplining Death

Conclusion
I can sum up what’s most exciting about working here in one word—hope.
(Douglas Amann, Pfizer, 2005: 27)
Medicine powerfully mediates the relationship between life and death. In
this paper, I have argued that medicine produces a pathological mortal
subjectivity, which is to say that it invites individuals to relate to death in an
antagonistic, impersonal, and technical fashion. While medicine provides
a number of existential discourses through which this subjectivity may
be produced, I have taken up the example of hypertension management,
for this discourse not only already implicates a great number of people,
reaching deep into their lifeworld, but because commercial pressures would
indicate its continued expansion. Through the example of blood pressure
regulation it is possible to get a sense of the way a variety of disciplinary
technologies, from public health literature to lifestyle modifications, train
individuals to experience death as disease, to respond to signs of mortality
via medical interventions, and to approach living instrumentally as a means
to longevity.
This article should not be taken as a rejection of hypertension manage-
ment nor the ethic of longevity. There is a place for these practices and
values as part of a broader whole. Rather my concern has been with the
ethico-political dimensions of health, motivated by the recognition that
health is intimately tied to questions of mortality and the determination of
what it means to live a worthwhile life. By troubling medical representations
of death, it has been my intention to begin to rethink health, such that it
may contain mortality and encompass a variety of styles of life and ethical
orientations.
There is much to be gained from thinking differently about the ‘health-
death’ relation, as hospice/palliative care has shown. Unfortunately, what-
ever benefits might be accrued from hospice’s efforts tend to be contained
on the yonder side of life – separated from the ‘living’ by the Berlin Wall of a
terminal diagnosis. There are, of course, other traditions to draw from.
Existential philosophy and secular forms of meditation view death as part
of life (Banerjee, 2006). Indeed, they claim that confronting and engaging
with death is integral to living well. Visions of health within these traditions
are consequently reshaped, having less to do with future probabilities
and more to do with a profound engagement with the present. They are
connected to notions of vitality and awareness, and the hope for security
through witnessing, accepting or transcending human limitation rather than
from strategies of control. We need to explore, carefully and critically, the
possibilities that these may afford.

Notes
1. For the sake of brevity, my use of the term ‘biomedicine’ is intended to include
both biomedicine and its extension beyond the clinic via forms of surveillance
medicine.

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health: 12(1)
2. The concept of dicipline was elaborated by Foucault (1977: 135–228) to
distinguish a form of power that emerged during the 18th century and shaped
the operations of numerous institutions, including prisons, hospitals, schools,
factories and the military. Disciplinary power employs a broad range of
seemingly minor techniques – e.g. tables, charts, standards, schedules, exams,
exercises – that share a number of common features, specifically: normalization,
which refers to the use of rationally defined norms to judge and correct the
operations of the body; continuous survelliance, which enables deviances
to be identified and interventions made; and partitioning, which effectively
subdivides the forces of interest into smaller and smaller units so that control
may be maximally refined. What is unique about discipline, and indeed much
of Foucault’s writing on power, is that it offers an understanding of power as
productive: “power produces; it produces reality; it produces domains of objects
and rituals of truth. The individual and the knowledge that may be gained of
him [sic] belong to this production” (194).

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Author Biography
albert banerjee is a PhD Candidate in Sociology at York University. Besides
researching and publishing on end-of-life issues such as hospice, euthanasia, and
long-term care, he is currently examining the politics of alternative health. He lives
in Toronto, Canada.

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